Dr Graham Ellis
Aboriginal Health
Dermatology
Rosacea
Table of Contents |
Incidence
The most likely diagnosis of a chronically red face is rosacea. Erythema occurs in a "cruciate" distribution affecting the cheeks, forehead, nose, chin and occasionally the balding male scalp. It is usually bilaterally symmetrical and most common in females of Celtic origin.There are two peaks in age of onset - 20's to 30's and the 40's to 50's. Rosacea starts with episodic flushing which gradually gives way to a fixed erythema. Persistent telangiectasia develops in the affected area and acute inflammatory episodes may occur with the formation of non tender papules and pustules. The role of the Demadex follicularum mite in the pathogenesis of rosacea is still unclear but a local delayed hypersensitivity response to Demadex antigens may be partly responsible for the inflammatory component.
First line treatments are topical antibiotics eg., metronidazole
0.75% gel twice daily. Alternatively clindamycin 2% lotion may be
used. If the alcohol base is too drying, it can be reformulated in
Cetaphil lotion. If there is no improvement after eight weeks,
systemic antibiotics should be started eg. Tetracycline 250mg QID,
minocycline or doxycycline 50mg BD. If these agents cause nausea or
photosensitivity, erythromycin 500mg BD or metronidazole 200mg may
be used. Treatment time is at least eight weeks and some patients
require long term maintenance therapy. Severe recalcitrant rosacea
may require isotretinoin. Facial erythema can be difficult to treat,
may be unresponsive to antibiotics, but persistent telangiectasia can
be helped by vascular laser therapy.
Dr Graham Ellis,
GP
Precipitants
Precipitating stimuli for rosacea include heat, UV light, spicy
foods, stress, exercise, alcohol and hot tea or coffee.
Differential Diagnosis
The differential diagnosis includes:
Management
Management involves identifying and avoiding any precipitating
factors. All sources of heat, such as excessively hot baths or
showers, saunas, direct radiant heat and hot beverages should be
avoided. Exposure to ultraviolet light should be limited and
sunscreen used. Intake of spicy food and alcohol should be reduced
or eliminated. An extractor fan in the kitchen to minimise the heat
from steam while cooking may be worthwhile. Cotton sheets and as few
blankets as possible will minimise overheating at night and excessive
room heating during winter should be avoided.
Complications
Rhinophyma, a bulbous swelling of the nose due to sebaceous gland
hyperplasia is the commonest complication of rosacea. This can be
treated surgically by paring or CO2 laser therapy. Up to 50% of
patients have inflammatory ocular complications such as
conjunctivitis or blepharitis. Rosacea keratitis needs early
recognition and treatment with steroid eyedrops to prevent corneal
scarring.
Tip
Avoid potent steroids in rosacea, and only use
hydrocortisone for short periods.
Goonellebah Medical Centre, gmc@nor.com.au
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